Management of anticoagulation for cancer‐associated thrombosis in patients with thrombocytopenia: A systematic review

Objective: Research is needed to guide the timing and safety of rehabilitation (physical and occupational therapy) in patients with acute deep venous thrombosis (DVT) that is untreated due to contraindications. Case Description: A 21-year-old man with Hodgkin lymphoma was admitted to the hospital for neutropenic fever. He developed gastrointestinal bleeding, diffuse alveolar hemorrhage, and bilateral lower-extremity DVT. He was not a candidate for chemical anticoagulation or placement of an inferior vena cava filter owing to thrombocytopenia. Rehabilitation was initially deferred because of concern that the thrombus could travel to the lungs, causing a pulmonary embolism. Rehabilitation was, however, started 4 days after the initial diagnosis of lower-extremity DVT to assess functional mobility and activities of daily living skills to prepare for discharge from the hospital. Results: The patient experienced no bleeding events during rehabilitation, and his acute, untreated DVT did not propagate based on clinical assessment. His Activity Measure for Post-Acute Care (AM-PAC) “6 Clicks” Basic Mobility score improved from 30.25 to 35.55 over the period of 11 days while he received rehabilitation. Conclusion: Despite having an acute bilateral lower-extremity DVT that was untreatable owing to thrombocytopenia, the patient successfully participated in rehabilitation and improved his physical functional status without an adverse event. Untreated acute venous thromboembolism in the setting of recent history of major bleeding raise concerns about physical activity restrictions. It is critical to consider both the risks and benefits of mobilizing patients and prescribing exercises in patients with these conditions.

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“…Such situations are particularly common in patients with cancer, in whom thrombocytopenia is often coupled with a hypercoagulable state. 14 …”

Section: Discussionmentioning

confidence: 99%

Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis

Pally

Tennison

2022

Integr Cancer Ther

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“…Thrombocytopenia increases the risk of bleeding complications in patients with CAT [ 43 ]. Unfortunately, there is limited evidence to guide management in patients with platelet counts <50,000 platelets/mL.…”

Section: Discussionmentioning

confidence: 99%

Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus

et al. 2021

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Patients with cancer-associated thrombosis (CAT) are at high risk of recurrent venous thromboembolism (VTE) and major bleeding complications. Risks vary significantly between individuals based on cancer status, treatment, and other characteristics. To facilitate the evidence-based management of anticoagulant therapy in this patient population, a committee of 11 Canadian clinical experts updated a consensus-based algorithm for the acute and extended treatment of symptomatic and incidental CAT that was developed in 2018. Following a systematic review of the literature, updates to the algorithm were discussed during an online teleconference, and the algorithm was subsequently refined based on feedback from committee members. Clinicians using this treatment algorithm should consider bleeding risk, type of cancer, and drug–drug interactions, as well as patient and clinician preferences, in tailoring anticoagulation for patients with CAT. Anticoagulant therapy should be adapted as the patient’s cancer status and management change over time.

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“…Lower thrombotic risk scenarios where full-dose anticoagulation may not be justified include non-acute VTE (especially in autologous hematopoietic stem cell transplantation), catheter-related thrombosis and low risk atrial fibrillation [114,125,126,129]. Strategies for mitigating the high bleeding risk associated with continued anticoagulation include increased platelet transfusion threshold (e.g., 40-50 × 10 9 /L) and anticoagulation dose reductions, but evidence proving the safety and efficacy of both approaches is lacking [130].…”

Section: Anticoagulationmentioning

confidence: 99%

Challenges and Advances in Managing Thrombocytopenic Cancer Patients

Leader

Hofstetter

Spectre

2021

JCM

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Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.

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Management of anticoagulation for cancer‐associated thrombosis in patients with thrombocytopenia: A systematic review

Cited by 57 publications

References 30 publications

Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis

Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis

Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus

Challenges and Advances in Managing Thrombocytopenic Cancer Patients

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